Radiology of adolescent slipped capital femoral epiphysis: measurement of epiphyseal angles and diagnosis.

UNLABELLED: AIMS OF DIAGNOSTIC RADIOGRAPHY: Visualization of the proximal femur in two clearly defined projections. Radiologic and morphological diagnosis of slipped capital femoral epiphysis. Evaluation of the stability of the femoral epiphysis: chronic slippage or acute interruption of continuity between the femoral epiphysis and the femoral neck metaphysis. Radiometric measurement of the spatial deformity of the femoral epiphysis. Measurement of the projected epiphyseal angle on the radiograph as the basis for possible conversion into anatomically correct angles at the proximal femur. Preoperative planning of therapeutic surgical procedures.

INDICATIONS FOR RADIOGRAPHIC IMAGING OF THE HIP JOINT IN TWO PLANES: Idiopathic hip pain in the growing child or adolescent. Referred pain to the knee or thigh. Unusual gait pattern with external rotation deformity of the leg, limping that favors one leg or limping due to leg length discrepancy. Abnormal sonography, CT or MRI findings. Eventful history including minor injury or genuine trauma. Symptoms and uncommon physical constitution: obesity, exceptional longitudinal growth of the extremities, and absence of secondary sex characteristics. Indications for Radiographic Imaging of the Hip Joint in Two Planes

CONTRAINDICATIONS: None.

RADIOLOGIC TECHNIQUE: Standard positioning of the patient or the affected extremity. First standard radiograph: proximal femur in anteroposterior projection. Position of the leg with the patella directed anteriorly. Contraction of the external rotators at the hip joint is compensated by elevation of the hip until the leg is in the neutral position. Second standard radiograph: axial view of the proximal femur in anteroposterior projection. Leg flexed to 90 degrees at the hip and in 45 degrees abduction. Thigh position parallel to the longitudinal axis of the table (zero rotation).

RADIOLOGIC MORPHOLOGY: Early signs of incipient or imminent femoral epiphyseolysis: --Disintegration, widening and blurred margins of the epiphyseal plate. --Increasing loss of height of the femoral epiphysis due to incipient dislocation. --The tangent to the lateral femoral neck intersects only slightly with the femoral head or runs tangential to the epiphysis. --Important second radiograph in axial projection: incipient slippage is seen early here. Comparison with the contralateral side. Chronic slipped capital femoral epiphysis in adolescents: --Advanced epiphyseal dislocation visible in both planes. The tangent to the lateral femoral neck no longer intersects with the dislocated femoral epiphysis. In some cases, varus deformity of the femoral neck and periosteal elevation at the borders of the medial femoral neck. --Epiphyseal dislocation even more apparent in the axial view. Acute slipped capital femoral epiphysis in adolescents: --Complete interruption of continuity between epiphysis and metaphysis. --Widened gap between epiphysis and metaphysis. --Cystic irregularities of the metaphysis. --In most cases, substantial dislocation between epiphysis and metaphysis. --"Acute on chronic slip": specific type of acute epiphyseal dislocation subsequent to chronic epiphyseolysis. In addition to signs of acute separation, secondary symptoms of chronic epiphyseolysis such as femoral neck arcuation and spur formation at the head-neck junction. --Dynamic fluoroscopy may be indicated to confirm acute dislocation.

EVALUATION OF RADIOGRAPHIC FINDINGS: Defined axes are marked on the radiograph: anatomic axis of the femur, femoral neck axis, and so-called epiphyseal axis (perpendicular to the base of the epiphysis). Measurement of the projected epiphysis-diaphysis angle (ED' angle) on the anteroposterior radiograph and the projected epiphyseal torsion angle (ET' angle) on the axial radiograph.

DEFINITION OF THE ANATOMIC DISLOCATION ANGLES OF THE FEMORAL EPIPHYSIS (ED AND ET ANGLES) AT THE PROXIMAL FEMUR: For slight to moderate slippage, the difference between the epiphyseal dislocation angle obtained from the radiographs (as projected in two planes) compared with the anatomic, i.e., real dislocation angle at the proximal femur is generally relatively minor. Conversion of the projected angle to the real angle is not essential in these cases (if in doubt, see Table 1). For more severe dislocations, the differences between the projected and real angles are far more apparent. Table 1 facilitates conversion of the epiphyseal dislocation angles taken from the radiograph into anatomically correct dislocation angles at the proximal femur. Conversion to real angles, especially for preoperative planning of complex corrective surgery, is indicated for more severe deformities of the femoral epiphysis. Conversion into real (anatomic) angles is indicated for exact prognostic evaluation of prearthrotic deformities.